PURPOSE OF THE JOB

The purpose of this job is to support the Electronic Data Interchange (EDI) program, through handling compliance for multiple jurisdictions across multiple lines of business by ensuring performance standards are met, efficiency of reporting and data quality. This role provides support to the internal Claims team, along with other analytical and project-based support functions within the department in support of business and company goals.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Supports regulatory reporting, research, and compliance data management

• Collects, organizes, and analyzes claims, financial, and operational data to support reporting and business needs.

• Documents and maintains procedures on the various components of EDI reporting.

• Gains an understanding of the policies, procedures, and operations of the various reporting entities, including Medicare reporting, FROI/SROI reporting, IDC reporting to ensure compliance standards are met.

• Partners with Claims, Compliance, and business stakeholders to support operational and compliance objectives.

• Monitors industry and regulatory updates to support the implementation of compliance-related changes.

• Assists with special projects assigned by management.

Analyzes claims data to identify areas of non-compliance

• Reconciles daily FROI/SROI diaries to ensure timely and successful transmission of claims data to various reporting agencies / rating bureaus.

• Completes various forms of transactional tracking to ensure efficiency, timeliness and accuracy of reporting.

• Supports Medicare Section 111 reporting processes and compliance with federal regulations.

• Reconciles data errors and corrections for indemnity payments as required by rating bureaus.

• Analyzes and validates data at the time of submission, corrects errors and troubleshoots issues with documentation or vendors.

• Monitors, researches, and resolves state notices related to reporting discrepancies to maintain compliance with EDI reporting requirements.

• Reviews claims-related materials for accuracy and compliance, escalating concerns as needed.

• Notifies and works with appropriate Claims Team Members to resolve errors.

Manages daily inbound and outbound data flow of EDI traffic

• Partners with the Claims team to resolve errors and provide support on EDI processes, protocols, and system usage.

• Monitors EDI queue and assists in clearing backlog diaries, emails, and issues as needed in support of the Supervisor.

• Distributes reports to appropriate teams according to department procedures and policies.

Identifies opportunities for continuous improvement

• Identifies workflow, system, and data integrity issues, recommending and supporting solutions to improve efficiency, compliance, and data quality.

• Assists in developing and implementing process improvements, regulatory compliance changes, and operational enhancements.

• Maintains department SharePoint content and support system enhancements, departmental initiatives, and special projects.

Participates and supports trainings to educate Claims Team on regulatory processes

• Provides feedback on training needs and reinforces key concepts to support regulatory compliance.

• Supports with the creation and maintenance of comprehensive training materials/curriculums as needed.

• Assists with facilitating training classes to various workers’ compensation claims audiences as needed.

Collaborates with internal teams, technology teams, and state agencies to manage EDI processes

• Collaborates with internal teams, external stakeholders, and regulatory agencies to facilitate data collection, resolve data-related queries and ensure effective communication of the EDI process.

• Provides support during the implementation phase of EDI projects to assist in development of initial testing plans and participate in user acceptance testing.

• Collaborates with IT Teams, EDI vendor(s), and other State or Federal agencies to identify areas of opportunity and resolve issues.

SUPERVISORY RESPONSIBILITIES

This role does not have supervisory responsibilities.

EDUCATION AND EXPERIENCE

High school diploma or GED required; college coursework toward an associate or bachelor’s degree preferred. Minimum of 2+ years of claims insurance or closely related experience required. Familiarity with claims electronic data interchange (EDI) is strongly preferred.

CERTIFICATES, LICENSES, REGISTRATIONS

None required

KNOWLEDGE AND SKILLS

• Must be proficient in Microsoft Office (Excel, Word, PowerPoint, and Outlook) and with compliance management software and tools.

• Must possess intermediate to advanced data entry skills with the ability to learn enterprise and department specific applications.

• Good understanding of insurance claims principles and practices.

• Analytical, problem-solving, detail oriented, attention to detail, organization skills required.

• Excellent communication (verbal/written) and interpersonal skills required.

• Must have the ability to:

  • Interpret complex laws and compliance measures.

  • Complete complex tasks, assignments, and defined processes under supervision.

PHYSICAL REQUIREMENTS 

Office environment – no specific or unusual physical or environmental demands and employees are regularly required to sit, walk, stand, talk, and hear. 

WORK ENVIRONMENT 

This position operates in an office environment and requires the frequent use of a computer, telephone, copier, and other standard office equipment.

This description is a general statement of essential job functions and responsibilities.

The position may include other duties as assigned.